Disclosures: Dr. Shrestha is on the
Medical Advisory Boards of Nuance Inc. and Vital Images, Inc., as well
as on the Editorial Board of Applied Radiology, and the Advisory Board of KLAS Research.

The
vendor neutral archive (VNA) is today more than just a catchy buzzword. Radiology departments across the country are working with enterprise information
technology (IT) to actively adopt or consider adopting a VNA, which
serves as an enterprise imaging repository sourcing data from,
potentially, all specialties—radiology, cardiology, pathology,
ophthalmology, etc.

However, VNAs have often been misunderstood, misinterpreted and over- or under-represented.

The
core objective of VNAs is to enable healthcare facilities to streamline
distribution, storage, and access to imaging and imaging- related data
from different departments through using the facility’s existing
solutions, such as any picture archiving and communications system
(PACS) or electronic medical record (EMR) and so on. The theory, at
least, is that this would provide a newfound freedom to provider
organizations with regards to decisions and cost-effectiveness around
image archiving, and not have to be held hostage to application vendors
who may have proprietary, application-centric, or costlier ways to
handle content management.

The reluctant emergence of VNAs

VNAs are a big buzzword1 these
days, but just a few years ago, not everyone was so keen on this
growing trend. PACS vendors at that time were happy selling a complete
solution, and providers were just as happy buying these complete
solutions from the vendors, with the goal of reaping the historical
benefits of the compelling return of investment (ROI) in going from film
to filmless, and the compelling benefits to be had from a clinical and
operational productivity perspective.

The notion of decoupling
the PACS from the archive, and the desire for a VNA started when a
number of providers recognized a key driver—with growing needs and
increasing maturity of their systems and organizations, their data was
seemingly being held hostage by their application vendors.

The desire to decouple the PACS from the archive soon grew to a logical need, and this need has now evolved into a market demand.
This progression can be deemed a natural evolution, as opposed to a
revolution, and is clearly a sign that the imaging industry is maturing.

But this maturity did not necessarily come willingly. As the VNA
‘buzz’ caught on, some PACS vendors initially and naturally denied the
very need for this ‘radical’ approach. Many of the reasons they
cited had and continue to have validation at certain levels. For
example, application performance and responsiveness was seemingly tied
directly to the application vendors’ needing to hog the content and hog
it in their own proprietary terms. When the cries for VNAs started to
get louder, the application vendors started to see an important part of
their business begin to be overtaken by emerging expertise focused
around infrastructure and content migration. And quite ingeniously, some
of the same vendors started to adopt a ‘me too’ strategy, where the
PACS vendors attempted to convince the providers that they now have a
PACS front end with a VNA of their own! This was achieved either with
organic growth, in concert with content migration vendors or, in some
cases, with acquisitions. Infrastructure vendors were quick on their
game, too, trying to “milk the VNA cow,” alongside thoroughbred VNA
vendors. This mishmash of various approaches and varying levels of
competence in VNAs perhaps is a seemingly natural progression too.

The healthcare information technology market continues to react in various ways to this emerging trend and evolving need.2 Fortunately,
however, we are certainly at a point today where there is both an
acceptance of the concept of a VNA and, more importantly, increasing
clarity around what a true VNA could and should look like. However,
stark differences still exist across the many choices of VNAs in the
marketplace.

Decoupling the PACS from the archive

The
stalwart proponents of the VNA essentially want to ensure that the
industry continues to move towards achieving a functional level of
decoupling the PACS application layer from the archive layer. Decoupling
the PACS from the archive clearly has many benefits. These include the
following:

Flexibility

A VNA offers the
promise of more flexibility, which comes in handy with adding new
imaging systems online, consolidating systems or switching from one PACS
to another. The largest growing segment of the PACS market today is the
replacement market, and medical facilities are seeking more flexibility
in handling and future-proofing their imaging content management so as
to mitigate complex data migrations.

Cost control

A
unified and streamlined management of images and related content in a
VNA holds the promise of reducing costs by eliminating or mitigating
costly data migrations and limiting the number of interfaces required to
image enable institutional information systems, eg, the electronic
health record (EHR). Centrally managed storage solutions have been shown
to lead to reduced total cost of ownership in a relatively short period
of time, and multi-phased progressive VNA deployments have been shown
to bear good returns.

Access

A consolidated
and controlled VNA streamlines enterprise access to images and related
content, enabling efficient retrieval of content from anywhere, across
any application or system. Ideally configured, this could guarantee
always on access to imaging content, even if the PACS is down. Growing
access needs could also be streamlined, such as for patient portals,
cloud-based image exchanges3, and more.

Intelligent data management

Decoupling of the PACS from the archive also allows for intelligent information lifecycle management4 policies
to be put in place and policed, centrally, and with more uniformity and
control. As organizations mature, and information systems grow in
number and complexity, it is critical to be able to centrally manage and
utilize the data intelligently, especially for effective clinical use.

Compelling componentization

The
growing maturity of the imaging workflow today calls for a compelling
argument for a move away from the one-stop-shop model of the legacy PACS
to one where componentization of various logical modules are possible.
PACS vendors are best left to handle the complex and critical workflows
that define the front-end PACS experience. Indeed, many provider
organizations today have more than one PACS across radiology,
cardiology, and other growing “-ologies.” Healthcare organizational
structures are getting more complex. The ecosystem of imaging
applications needs to thrive on a robust vendor-agnostic archive that
comprises a scalable and flexible-backed storage platform layer that
snugly sits below a standards based middleware layer. This layer
provides image and information management capabilities with wide ranging
support for intra- as well as inter-departmental, enterprise as well as
broader regional workflows.

Such level of componentization
ensures a level of maturity not possible before, and provides each
module with the freedom to progress further.

A robust VNA should
have support for both DICOM and non-DICOM content, including waveforms,
movie files, and audio files, all in their native formats. There should
be full support for various IHE5 profiles, including
cross-enterprise document sharing (XDS and XDS-i). Context management of
data across various sources along with support for complex tag morphing
rules is critical, as is the capability to support the full suite of
DICOM SOP classes, including various presentation states and disparate
key image notes from multiple applications.

Of critical
importance, however, is the workflow layer that is enabled by the
middleware and storage layers. A robustly designed VNA—integrated with
the institutional informatics solutions—enables standards-based
information management and effective clinical workflow management.
Otherwise, without robust workflow enablement, a VNA may just end up as
an expensive paperweight. This should be true for complex and
well-defined workflows, such as those found in radiology and cardiology,
and less-defined workflows that may be more EMR focused, such as those
found in wound imaging and otolaryngology. This level of maturity
enables a streamlined and workflow-oriented clinical content foundation
that is patient-centric and interoperable across various applications.

Déjà vu all over again

The
main issue at hand is that of control. With VNAs, providers are seeking
to regain some of that control from the application vendors. But
control is a funny beast. The moment you take steps to free yourself
from the shackles of your application vendors, you wake up to realize
that you have tied yourself to the confines dictated by your VNA vendor.

It’s like déjà vu all over again. So, what’s one to do? There are 3 things to keep in mind here in addressing this dilemma.

Better the devil you know

First
is the fact that the complexities and challenges afforded by multiple
application vendors are best handled by a controlled entity working on
your terms with nonproprietary, standards-based approaches to archiving
and content management. A streamlined, controlled enterprise approach
with a single “throat-to-choke” can be just what the doctor ordered—as
long as the entire VNA-based ecosystem is designed around long-term
institutional needs.

Longer lifecycle

PACS replacements6 are
considered every 5 to 7 years, whereas major infrastructure decisions,
such as VNAs, have a much longer lifecycle, closer perhaps to 15 to 20
years.

In the long run, standards rule

The
most valuable “get out of jail free card” in the VNA game, however, has
to be the push for strict adherence to industry standards. The icing on
the cake will be a VNA partner who provides a future-proof platform that
allows for growth with next-generation storage devices and
capabilities.

Riding the VNA spectrum

The spectrum
of vendors selling VNAs (oh, the irony!) continues to evolve. There are 3
key categories that one needs to keep in mind:

Thoroughbreds

Most
of the thoroughbred VNA vendors started off with key expertises in
DICOM data migration (eg, Acuo, DeJarnette, DICOM Grid, Teramedica,
etc.). They are often seen in the industry as the ‘purists,’ often
touting the fact that if you truly want to decouple your PACS from your
archive, then you clearly cannot rely on your PACS vendor to do this.
Enter the thoroughbreds. Their experience dealing with all things data
migration and content management is their biggest asset.

PACS VNAs

As
explained above, as VNAs gained momentum, some PACS companies
engineered, acquired, or partnered with VNA companies and touted their
own VNAs. The range and competency in this category is wide, and while
some in the industry did not take the “me-too” resurgence from the PACS
companies too seriously, several key PACS players are today
reengineering robust content management capabilities, which when married
with the inherent workflow finesse, could make for a formidable story.

Infrastructure VNAs

Traditional
infrastructure companies (eg, Dell, EMC, Hitachi, IBM, etc.) have
entered the VNA race, too, and were perhaps always there from the
beginning. They bring their strengths around storage architecture and
intricate deployment options. Telecommunications and consultancy
companies frequently form tight alliances with the infrastructure VNA
vendors, often through partnerships or acquisitions, and offering a
unique perspective on solving complex challenges.

Not all VNA
solutions are created equal, however, and as each of these categories
continues to evolve, the story keeps on getting better for all of us.
Enterprise content management (ECM) firms bridging with VNAs seems to be
the next logical evolution,7 and this makes for perfect
sense in terms of a broader strategy to manage all content across the
healthcare enterprise. Across the board, there is a push for greater
degrees of maturity around content management in healthcare, and my
prediction is for continued innovation in this area.

Enterprise
vendor-neutral archives have the potential to dramatically shift the way
health care is practiced, enabling the transformation to true
collaborative care with meaningful data interoperability across imaging
and related clinical content—providing a compellingly strong foundation
for patient-centered care.

About the Author

Dr. Shrestha is the Chief Innovation Officer at University of Pittsburgh Medical Center, Pittsburgh, PA, and Executive Vice President of UPMC Enterprises. He is also Chair of the RSNA
Informatics Scientific Program Committee; a Founding Member of the
Executive Advisory Program, GE Healthcare; a member of the advisory
boards of KLAS Research and Peer60; a member of the Board of Directors
of the Society for Imaging Informatics in Medicine; a member of the
boards of Pittsburgh Dataworks and Omnyx Inc., and a member of the Applied Radiology editorial board.